Question

What is the moral difference (if one exists) between withholding treatment and withdrawing treatment according to Panicola? Between killing a patient (euthanasia) and allowing a patient to die by forgoing treatment that is excessively burdensome? Explain.

Answer 1

End-of-life situations are among the most prominent areas of controversy in contemporary bioethics. To this day, very few countries have taken the radical approach of accepting the direct termination of life by a medical practitioner. Most countries stick to the traditional interdiction of voluntary active euthanasia. This makes it very much likely that controversy will continue to center on the practice of withholding and withdrawing medical treatment, with particular reference to life-sustaining treatments. To withhold or withdraw some forms of treatment, in fact, is the simplest way to defend patients from possibly unwanted negative consequences of life-prolonging medical technology, especially when the patient’s quality of life lowers dramatically.

Traditionally, medicine has been focused on extending life. However as death approaches, extending life may not be in the best interests of the patient. A number of treatments and interventions can artificially extend life at end of life: certain medications, artificial nutrition, treatments such as dialysis, transfusions, radiation, and ventilation for breathing. It is important that patients and families understand the intent and possible risks or benefits of the care they are receiving. While withholding treatment and withdrawing treatment refer to actions taken by health care providers, the actual decision to decline or discontinue treatment rests with the patient or the patient’s family or substitute decision-maker. Declining or discontinuing treatments that artificially extend life doesn’t mean that symptom control such as pain management and emotional support stop. Care and treatment focused on maintaining comfort continue, allowing the person to die naturally from the disease.

Life Prolonging Treatment (LPT): is any medical intervention, technology, procedure or medication that is administered to provide benefit for a patient and to forestall the moment of death. These treatments may include, but are not limited to, mechanical ventilation, artificial hydration and nutrition, cardiopulmonary resuscitation, haemodialysis, chemotherapy, or certain medications including antibiotics.

Withholding a Particular Treatment for a particular patient is generally viewed as morally justified if the treatment is considered futile (without benefit) or unnecessarily burdensome. It is often recommended that decisions by a healthcare team to withhold life supporting treatment require the consent of the patient and/or the patient’s family. However, such a viewpoint about the obligation to achieve consent of patient/or family is contested. This would especially be the case when the treatment under consideration is, on the basis of clinical evidence, deemed futile. However, where conversation with patient/and or family is pursued, an essential element in that conversation is that it must provide information on the nature of the treatment under consideration, the likely consequences of its use, and the benefits and/or burdens expected in the use of a particular LPT. This level of information is essential to help achieve patient and/or family understanding so that they are better positioned to give genuine and valid authorisation for refusal of LPTs.

Withdrawing Treatment Already Begun is legally and ethically justified if it can be shown that the burdens of continued treatment for a particular patient outweigh the benefits. If a patient is competent and if they so wish, they should be central in the determination of what constitutes a ‘burden’. Withdrawal is normally a decision taken with the patient and/or the patient’s family through conversation about the patient’s sufferings and prognosis. If a patient lacks capacity, then the health professional, usually in conjunction with any family or proxy, determines what is in the ‘best interests’ of the patient.

Euthanasia: is a deliberate act or omission whose primary intention is to end another person’s life. Literally, it means a gentle or easy death but it has come to mean a deliberate intervention by one person with the clear intention of ending the life of another. This is often described as ‘mercy killing’ of people in pain with terminal illness. Decisions to withdraw or discontinue LPTs are not equivalent to euthanasia if they are validly authorised by a competent patient’s consent or if a clinical decision is made that further life supports, based on all available evidence, would be futile – lacking in benefit for the patient and merely prolonging the dying process.